Healthcare Provider Details

I. General information

NPI: 1316202575
Provider Name (Legal Business Name): SETH N J MALLAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W CARLETON RD
HILLSDALE MI
49242-5034
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-212-8140
  • Fax: 517-212-8141
Mailing address:
  • Phone: 517-748-5500
  • Fax: 517-783-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101019724
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: